Increasingly, nursing homes (NHs) are the final place of care for frail older adults: Yet research suggests the quality of end-of-life (EoL) care in NHs is far less than optimal. Much remains unknown about the strategies NHs use for providing EoL care and how these care strategies affect quality outcomes. We do know hospice care in NHs is associated with higher quality EoL care, but we also know hospice use in NHs varies substantially across states, and this appears to be associated with a state's LTC policies. This proposal will test how changes in state policies are associated with changing hospice use and access. Also, it will test how state policies are associated with the differing care strategies chosen by NHs for providing EOL care; whether, based on the Resource Dependency theory and Transaction Cost Economics, observed associations differ by organization and market characteristics; and how differing EoL care strategies are associated with NH processes and quality outcomes for dying NH residents/families. Specific aims are: 1. Describe the differing use of Medicare hospice care in NHs and the range of NH investment in EoL palliative care: a. Describe variations in hospice use and access in the US over a 10year period and in relation to changes in selected state policies; b. Among surveyed NHs, characterize the degree of collaborative NH/hospice sharing and explore how this is associated with the amount of hospice used by a NH; c. Among surveyed NHs, 1) Create a "palliative care "score, reflecting the extent to which the NH's processes and structures reflect the "Core Elements of Palliative Care" (i.e., reflect NH's investment in palliative care); and 2) Describe the prevalence of the following four NH approaches to providing specialized EoL palliative care: i) hospice contracting, with little or no NHpalliative care investment, ii) NHinvestment in EoL palliative care (moderate and high levels of investment) without hospice contracting, Hi) a mix ofi and ii, and iv) neither i or ii. 2. Test the effect of changing state policies onthe volume of hospice useand the changes in access to care that increased use creates. 3. Test the effect of state policies in force on the strategic choice that NHs make as to how to provide EoL care (see c.1. above). 4. Test the effect that a NH's EoL care strategy has on a) NH-level processes and b) on clinical care outcomes experienced by terminal residents served in NHs and the extent to which the strategy was implemented. 5. Explore the effect that a NH's EoL care strategy (as above) and the extent to which the strategy was implemented has on the quality of life experienced by NHresidents/families. Lay Summary: Increasing numbers of individuals die in NHs but quality of care needs improvement. This study examines the impact of state policies and market factors on how NHs deliver end of life care and the quality of that care for residents.